Vonoprazan superior to PPI for heartburn resolution in erosive esophagitis patients

Vonoprazan 20 mg once daily (QD) appears as effective as proton pump inhibitors (PPIs) on day 1 and equally or more effective on day 7 in the treatment of heartburn in adults with erosive esophagitis, results of a network meta-analysis have shown.

“The primary endpoint of heartburn resolution rate on day 1 numerically favoured vonoprazan 20 mg QD over PPIs,” the researchers said. “For heartburn resolution rate on day 7, vonoprazan 20 mg QD was statistically superior to all PPIs assessed except for rabeprazole 20 mg QD.”

A systematic literature review was carried out using the databases of Medline and Central, followed by a network meta-analysis according to Cochrane and PRISMA guidelines. Studies included in the meta-analysis were randomized controlled trials in adults with erosive esophagitis treated with vonoprazan or a PPI. The researchers used a random effects model within a Bayesian framework to assess all data.

Ten trials met the eligibility criteria. On day 1, vonoprazan 20 mg QD achieved heartburn resolution better than placebo in nine of 10 trials (median odds ratio, 16.75, 95 percent credible interval, 2.16‒207.80). Point estimates favoured vonoprazan relative to other drugs. [J Clin Gastroenterol 2022;56:493-504]

On day 7, vonoprazan 20 mg QD also resolved heartburn and showed superiority over placebo and other comparators except rabeprazole 20 mg QD. Point estimates, however, were numerically in favour of vonoprazan vs rabeprazole 20 mg QD.

“The results of the current study are consistent with those of previous studies,” the researchers said. “We previously conducted a randomized, double-blind, head-to-head comparison of vonoprazan 20 mg QD and lansoprazole 30 mg QD.”

In the 2019 trial, vonoprazan 20 mg QD achieved heartburn resolution faster than lansoprazole 30 mg QD. The difference in symptom relief rate was 20 percent on day 1 and 40 percent on day 7, suggesting that efficacy was increasing over time. [Aliment Pharmacol Ther 2019;49:140-146]

“While PPIs take several days to exert their maximum effect, vonoprazan shows a strong acid secretion inhibitory effect from the first day of administration,” the researchers noted.

A study by Sakurai and colleagues revealed that, on day 1, the pH 5 holding time ratio was 13.0 percent for esomeprazole and 16.7 for rabeprazole compared with 62.8 percent and 76.6 percent for vonoprazan, respectively. On day 7, the ratio was 48.3 percent for esomeprazole and 53.2 percent for rabeprazole compared with 79.0 percent and 89.1 percent for vonoprazan, respectively. [Aliment Pharmacol Ther 2015;42:719-730]

“Although the mechanism between acid reflux and symptom onset has not been fully elucidated, it has been suggested that heartburn may be related to the local inflammatory response in the oesophageal epithelium, caused, in part, by acid stimulation,” the researchers said. [J Gastroenterol Hepatol 2013;28:385-387; Curr Opin Gastroenterol 2016;32:344-352; Am J Physiol Gastrointest Liver Physiol 2010;298:G571-G581]

“Thus, the strong and rapid acid secretory inhibition of vonoprazan might contribute to heartburn resolution on day 1 and day 7,” they added.